The Irish
Forensic Psychiatric Service
The Irish Forensic
Psychiatric Service is currently undergoing major change and
development. It is not
before time that it is to receive the long overdue investment
it requires to provide a high quality comprehensive range of
services to mentally disordered offenders.
The Central Mental Hospital is the national centre
for Forensic Psychiatry in the Republic of Ireland. It was established under the Criminal Lunatic Asylum Act of 1845
and opened in 1850, the first high security hospital in the
British Isles. It provided a service for the entire country
up until 1922 when partition occurred, and since then Northern
Ireland has it’s own Forensic service with access to secure
facilities at Carstairs. The Central Mental Hospital is built on a
34 acre site, four miles from Dublin city centre and thus within
easy access to courts and a number of main prisons.
The campus provides high, medium and low-level security,
which facilitates the stratification of risk along a rehabilitation
route.
Originally the bed capacity was 160, and archival records
make interesting reading, reflecting social, legal and psychiatric
practices over time. The
current bed capacity is 89, 7 of which are for females.
Of the total only 25 are acute, through which 160 admissions per year are processed. The remaining beds are medium and long-term, with over 30 of the
latter occupied by patients of low risk who could be managed
within the general psychiatric services but whose discharge
from the Central Mental Hospital is hampered by inadequate community
facilities.
Admissions come from three sources. Almost 1.37% of
all committals to prison are referred for admission (the Irish
prison population is 3,200).
We believe that this is the highest transfer rate from
prisons to a high security hospital in Europe. Our impression
is that there is an increasing level of people with severe mental
illness in the prison population and we are currently carrying
out a survey of 10% of all prisoners to confirm this.
A small number of admissions are transferred as tertiary
referrals from psychiatric hospitals in the community, under
the Mental Treatment Act of 1945, whose security needs exceed
local capacity. This group make up 2% of annual admissions
but currently account for 25% of bed occupancy in the hospital. A further small number are found guilty but
insane or are unfit to plead each year and must be detained
in the Central Mental Hospital under current legislation, at
the pleasure of the Government.
Current mental health and criminal justice legislation
does not meet the needs of the mentally disordered offender
or indeed the service providers to that group.
The existing legislation in relation to insanity and
unfitness is narrow and outdated – leading to indeterminacy
of detention without automatic review.
Release programmes which can be influenced by political
considerations may be at variance with a therapeutic approach.
We welcome proposed new legislation which will introduce
the verdict of diminished responsibility into this country,
which may lead to a broader range of disposal options available
to the courts and ultimately enhance more appropriate clinical
care pathways for these patients.
A new Mental Health Bill was enacted last year. We forensic psychiatrists, are less than satisfied
with its provisions and feel that our patients will be discriminated
against. There is no
proposed legislative framework for court diversion, compulsory
treatment in the community or automatic review for our criminally
detained patients. The original draft bill had included a chapter
focusing on these issues but this was dropped from the final
Bill altogether. We
have been promised a bill from the Department of Justice, Equality
and Law Reform to deal with mentally ill offenders but we have
reservation about this separation from the rights afforded to
other detained patients
Plans for the development of the Irish Forensic Service
are based on international standards of best practice and therapeutic
environments following our aggregated needs assessment survey
(H.K. and C.O’N 2001).
Major capital investment will upgrade the hospital to
a high standard (projected cost Є33 million) This will involve holding on to the original
facade of the hospital on which there is a preservation order,
and building new units with a total bed capacity of 90 and an
additional 30 low-secure places provided by two high support
hostels within the parameter of the hospital. Overall therefore, there will be an increase
of 31 beds within the service.
Rehabilitation facilities will also be greatly expanded.
In tandem with the building
development, major recruitment of additional human resources
is already under way. Up
until recently, there were two consultant psychiatrists (including
clinical director), one psychologist part-time, one social worker,
and seven non-consultant hospital doctors – for the entire
national forensic service.
Within the past two years, three additional consultant
forensic psychiatrists have been appointed along with a principle
psychologist. The aim
is that there will be five consultant led multi-disciplinary
teams. Registrar posts are rotated from a number of training
schemes and the service has been approved for specialist registrar
training. There are also two full-time research registrars and
a special lecturer.
Based on the findings of a
recent extensive survey among Irish psychiatrists, a new Irish
Section of the Royal College had been established.
Within this section, a Law Committee has been set up
to advise government departments and health boards on Mental
Health Legislation and to provide guidance to the Irish Section
on medico/legal aspects of psychiatric practice and services
in Ireland.
These are exciting times for
forensic psychiatry in Ireland.
The capital investment and increased human resources
will lead to modernisation and expansion in services.
The success of the development of the Forensic Service
will depend on the ongoing support and commitment from our Regional
Health Authority and local managers, our staff, good professional
relationships with our colleagues in the community and the confidence
from the public at large.
Dr
Helen O'Neill
Consultant Forensic Psychiatrist
